Kitsap Public Health District Consent Agenda Agreement

Kitsap Public Health District

Consent Agenda Agreement Summary

February 4, 2020

KPHD

Contract

Number

Their

Contract

Number

Contractor and

Agreement Name

Type of

Agreement

Term of

Agreement

Amount to

District

Amount to

Other

Agency

1749

Amendment 12

(2055)

CLH18248 Washington State Department of Health

Consolidated Contract

Amendment 01/01/2018-

12/31/2020

$11,500 $0

Description: Amends Statements of Work for Childhood Lead Poising Prevention Program, Infectious Disease Care & Prevention

(ICDP), Office of Drinking Water Group A Program and Office of Emergency Preparedness & Response and adds additional funding

of $11,500 for a revised maximum consideration of $5,716,677.

2054 People’s Harm Reduction Alliance Secondary Syringe Exchange

Contract 01/01/2020-

12/31/2020

$0 $75,000

Description: Contractor to provide county-wide mobile syringe exchange services in primarily rural areas as a component of the

District’s re-configured Kitsap Syringe Exchange Services Network. Mobile exchange services to be performed following Centers for

Disease Control and Prevention guidance and science-based behavioral health interventions. Contractor will integrate prevention

education, referral, and counseling services into the needle exchange program and provide overdose prevention, education, and training

in the administraton of naloxone in accordance with the Substance Abuse and Mental Health Services Administration (SAMHSA)

guidance. This contract completes the formal Request for Proposals process initiated by the District in 2019.

KITSAP PUBLIC HEALTH DISTRICT

2018 – 2020 CONSOLIDATED CONTRACT

Page 1 of 27

CONTRACT NUMBER: CLH18248 AMENDMENT NUMBER: 12

PURPOSE OF CHANGE: To amend this contract between the DEPARTMENT OF HEALTH hereinafter referred to as

“DOH”, and KITSAP PUBLIC HEALTH DISTRICT hereinafter referred to as “LHJ”, pursuant to the

Modifications/Waivers clause, and to make necessary changes within the scope of this contract and any subsequent

amendments thereto.

IT IS MUTUALLY AGREED: That the contract is hereby amended as follows:

1. Exhibit A Statements of Work, attached and incorporated by this reference, are amended as follows:

Adds Statements of Work for the following programs:

Amends Statements of Work for the following programs:

Childhood Lead Poisoning Prevention Program - Effective July 1, 2019

Infectious Disease Care & Prevention (IDCP) - Effective July 1, 2019

Office of Drinking Water Group A Program - Effective January 1, 2018

Office of Emergency Preparedness & Response - Effective July 1, 2019

Deletes Statements of Work for the following programs:

2. Exhibit B-12 Allocations, attached and incorporated by this reference, amends and replaces Exhibit B-11 Allocations

as follows:

Increase of $11,500 for a revised maximum consideration of $5,716,677.

Decrease of for a revised maximum consideration of .

No change in the maximum consideration of .

Exhibit B Allocations are attached only for informational purposes.

3. Exhibit C-12 Schedule of Federal Awards, attached and incorporated by this reference, amends and replaces

Exhibit C-11.

Unless designated otherwise herein, the effective date of this amendment is the date of execution.

ALL OTHER TERMS AND CONDITIONS of the original contract and any subsequent amendments remain in full force

and effect.

IN WITNESS WHEREOF, the undersigned has affixed his/her signature in execution thereof.

KITSAP PUBLIC HEALTH DISTRICT

________________________________________________

STATE OF WASHINGTON

DEPARTMENT OF HEALTH

____________________________________________

Date Date

APPROVED AS TO FORM ONLY

Assistant Attorney General

KPHD 2055Page 1 of 36

AMENDMENT #12

Exhibit A, Statements of Work Page 2 of 27 Contract Number CLH18248-12

Revised as of November 15, 2019

2018-2020 CONSOLIDATED CONTRACT

EXHIBIT A

STATEMENTS OF WORK

TABLE OF CONTENTS

DOH Program Name or Title: Childhood Lead Poisoning Prevention Program - Effective July 1, 2019 ........................................................................................ 3 DOH Program Name or Title: Infectious Disease Care & Prevention (IDCP) - Effective July 1, 2019 ........................................................................................... 6 DOH Program Name or Title: Office of Drinking Water Group A Program - Effective January 1, 2018 ...................................................................................... 14 DOH Program Name or Title: Office of Emergency Preparedness & Response - Effective July 1, 2019 ..................................................................................... 19


AMENDMENT #12



Exhibit A

Statement of Work

Contract Term: 2018-2020

DOH Program Name or Title: Childhood Lead Poisoning Prevention Program -

Effective July 1, 2019

Local Health Jurisdiction Name: Kitsap Public Health District

Contract Number: CLH18248

SOW Type: Original Revision # (for this SOW) 1 Funding Source

Federal <Select One>

State

Other

Federal Compliance

(check if applicable)

FFATA (Transparency Act)

Research & Development

Type of Payment

Reimbursement

Fixed Price Period of Performance: July 1, 2019 through June 30, 2020

Statement of Work Purpose: The purpose of this statement of work is to support local interventions with the case management of elevated blood lead levels in children 14 years

of age and younger. The focus of this program is to build local capacity statewide to provide case management services to all children with elevated blood lead levels.

Revision Purpose: The purpose of this revision is to move the funding from Healthy Communities (MI 25611100) to FPH Lead Case Mgmt - FPH (MI 25619702) for funding

period 07/01/19-06/30/20. The SOW and total consideration remains the same.

Chart of Accounts Program Name or Title CFDA # BARS

Revenue

Code

Master

Index

Code

Funding

(LHJ Use

Start Date

Period

Only)

End Date

Current

Consideration

Change

None

Total

Consideration

Healthy Communities N/A 334.04.91 25611100 07/01/19 06/30/20 3,425 -3,425 0

FPH Lead Case Mgmt - FPH N/A 334.04.93 25619702 07/01/19 06/30/20 0 3,425 3,425

TOTALS 3,425 0 3,425

Task

Number Task/Activity/Description

*May Support PHAB

Standards/Measures Deliverables/Outcomes

Due Date/Time

Frame

Payment

Information and/or

Amount

1 Home Visit 1

a) Contact the provider to gather complete

information on the assigned elevated blood lead

level case.

b) Contact the family to schedule the visit.

c) Visit the child’s residence (or other sites where the

child spends significant amounts of time).

d) Interview the caregivers using the Child Blood

Lead Investigation Form and conduct an

environmental assessment to identify factors that

may impact the child’s blood lead level.

e) Determine if the family lives in Section 8 or HUD

housing, and if the child is Medicaid enrolled.

f) Provide educational material to the child’s

caregivers in the family’s primary language.

Submit the information collected

during the home visit via the

applicable fields of the

Washington Disease Reporting

System (WDRS).

Submit, as attachment(s) via

WDRS the documentation of the

Plan of Care prepared for the

family (DOH will provide a

template) including a summary

of the environmental assessment

and suggestions for reducing or

eliminating exposure. Provide a

copy of this document or

Submit as needed

within 60 days

after completion.

Reimbursement of up

to $500 maximum

per home visit, per

child. Up to two (2)

home visits per child

not to exceed total

funding

consideration.

Note: this excludes

indirect costs.


AMENDMENT #12



Task


*May Support PHAB


Due Date/Time

Frame

Payment

Information and/or

Amount

g) Arrange with family and provider to have the child

retested following the Pediatric Environmental

Health Specialty Unit (PEHSU) medical

management guidelines:

https://www.pehsu.net/_Library/facts/medical-

mgmnt-childhood-lead-exposure-June-2013.pdf

documents to the child’s

caregivers and provider.

2 Home Visit 2 (optional)

a) The purpose of the optional second home visit is

to connect the family to other service providers,

explain recommendations, answer questions, and

provide any further needed assistance for the

family in implementing recommendations.

b) Facilitate the completion of a developmental

screening to be conducted by LHJ staff, via the

online WithinReach Developmental Screening

Questionnaire http://www.parenthelp123.org/ or

other methodology, or by referral to the child’s

physician or another entity trained to administer

developmental screening tests.

c) Encourage blood lead testing of other children less

than 72 months of age and pregnant or nursing

persons in the home.

d) If appropriate, refer the family to the Women,

Infants, and Children (WIC) program or a

Registered Dietitian Nutritionist for a nutritional

assessment and to other service providers as

appropriate.

e) Coordinate services and communicate with other

involved professionals.

Submit a new or updated Plan of

Care to DOH via WDRS and

provide a copy to the child’s

caregivers and provider that

includes:

a) A summary of the results

of any assessments

conducted by LHJ staff

and/or information on all

referrals made.

b) The names of any at-risk

family members referred

for blood lead testing.

c) The names of all

professionals who have

been part of the Plan of

Care or to which the family

has been referred for

services.

Submit as needed

within 60 days of

completion

Reimbursement of up

to $500 maximum

per home visit, per

child. Up to two (2)

home visits per child

not to exceed total

funding

consideration.

Note: this excludes

indirect costs.

3 DOH will reimburse LHJ for costs incurred for field

investigation sample laboratory testing, as well as costs

incurred for interpretation and/or translation services

needed as part of case management.

Submit vendor invoices to DOH

to document the reimbursement

request.

As needed. Total reimbursements

may not exceed total

funding

consideration.

(See Special Billing

Requirements

below.)


https://www.pehsu.net/_Library/facts/medical-mgmnt-childhood-lead-exposure-June-2013.pdf

https://www.pehsu.net/_Library/facts/medical-mgmnt-childhood-lead-exposure-June-2013.pdf

http://www.parenthelp123.org/

AMENDMENT #12



*For Information Only:

Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a

Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:

http://www.phaboard.org/wp-content/uploads/PHAB-Standards-and-Measures-Version-1.0.pdf

Program Specific Requirements/Narrative

Program Manual, Handbook, Policy References

Guide for Public Health Case Management of Children with Elevated Blood Lead Levels

https://www.doh.wa.gov/Portals/1/Documents/4000/334-414.pdf

A Targeted Approach to Blood Lead Screening in Children, Washington State

2015 Expert Panel Recommendations

https://www.doh.wa.gov/Portals/1/Documents/Pubs/334-383.pdf

Special References (RCWs, WACs, etc)

Laboratories are required to report to the Department of Health all Blood Lead test results (WAC 246-101-201). Elevated results (greater than or equal to 5 mcg/dL) must be

reported within two (2) days; non-elevated results need to be reported within one (1) month.

Monitoring Visits (frequency, type)

Telephone calls and/or in person meetings with contract manager on as as-needed basis.

Definitions

BLL – Blood Lead Level

EBLL – Elevated Blood Lead Level

PEHSU – Pediatric Environmental Health Specialty Units

Special Billing Requirements

The average total amount expended for laboratory, interpreter, and translation services is suggested to be approximately $185 per home visit, per child. It is recognized that more

complex cases may require a higher level of services, while simpler cases may require fewer services. Total reimbursements may not exceed total funding consideration.

Please note WDRS event number(s) on invoice to allow DOH review of deliverables via WDRS. Payment to completely expend the “Total Consideration” for a specific funding

period will not be processed until all deliverables are accepted and approved by DOH. Invoices may be submitted as needed within 60 days after home visit completion and must

be based on actual direct program costs. Billing for services on a monthly fraction of the “Total Consideration” will not be accepted or approved. If needed, additional funding

may be requested and upon DOH approval may be added if funds are available.

Note: Blood Lead Case Management reimbursement excludes indirect costs.

DOH Program Contact DOH Fiscal Contact

Amy Bertrand, Health Services Consultant/Case Management Coordinator Victoria Reyes, Management Analyst 1

Office of Environmental Health Sciences Assistant Secretary’s Office

Washington State Department of Health Telephone: 360-236-3071

Street Address: 310 Israel Rd SE, Tumwater WA 98501

Telephone: 360-236-3392 / Fax 360-236-3059

Email: [email protected]



https://www.doh.wa.gov/Portals/1/Documents/4000/334-414.pdf

https://www.doh.wa.gov/Portals/1/Documents/Pubs/334-383.pdf

mailto:[email protected]

AMENDMENT #12



Exhibit A

Statement of Work


DOH Program Name or Title: Infectious Disease Care & Prevention (IDCP) -




SOW Type: Revision Revision # (for this SOW) 1 Funding Source

Federal Subrecipient

State

Other

Federal Compliance




Type of Payment

Reimbursement


Statement of Work Purpose: The purpose of this statement of work is for the provision of a range of client-centered activities focused on improving health outcomes in support

of the HIV care continuum as well as to provide infectious disease (HIV, STD, and Adult Viral Hepatitis) prevention services.

Revision Purpose: The purpose of this revision is to remove $81,855 from FFY19 RW GRANT YEAR LOCAL (REBATE) (MI 1261859C) and $27,285 from FFY20 RW

GRANT YEAR LOCAL (REBATE) (MI 1261850C) and add $109,140 to FFY19 RYAN WHITE SUPP DIRECT SVCS (MI 12615293) for the period 09/30/19-06/30/20 and add

Special Requirements.


Revenue

Code

Master

Index

Code

Funding

(LHJ Use

Start Date

Period

Only)

End Date

Current

Consideration

Change

None

Total

Consideration

FFY19 RW GRANT YEAR LOCAL (REBATE) N/A 334.04.98 1261859C 07/01/19 03/31/20 348,437 -81,855 266,582

FFY20 RW GRANT YEAR LOCAL (REBATE) N/A 334.04.98 1261850C 04/01/20 06/30/20 116,146 -27,285 88,861

STATE DRUG USER HEALTH PROGRAM N/A 334.04.91 12405100 07/01/19 06/30/20 40,000 0 40,000

ADAP REBATE (LOCAL) 19-21 N/A 334.04.98 12618590 07/01/19 06/30/20 91,728 0 91,728

FFY19 RW LOCAL PROVISO N/A 334.04.98 12618595 07/01/19 06/30/20 41,749 0 41,749

FFY19 RYAN WHITE SUPP DIRECT SVCS 93.917 333.93.17 12615293 09/30/19 06/30/20 0 109,140 109,140

TOTALS 638,060 0 638,060

Task Number Task/Activity/Description Deliverables/Outcomes Due Date/Time Frame Payment Information and/or

Amount

Drug User Health

Syringe

Service

Program (SSP)

Syringe Service Program (SSP):

To provide comprehensive Syringe Service

Program (SSP) to people who use drugs

(PWUD). This plan of action is directed to

distribute syringes to communities that use drugs

to prevent transmission of infectious

disease. SSP programs will operate during

scheduled hours to provide new harm reduction

Identify and submit annual

projections for each of the SSP

deliverables.

Enter deliverable data into

database for tracking SSP activities

by the 15th of each month

following service.

Monthly by the 15th of the

following month. $40,000 – MI 12405100 –

State Drug User Health

$40,000 for 07/01/19-06/30/20


AMENDMENT #12




Amount

supplies and syringes to prevent transmission of

disease. SSP will offer referrals to address

social determinants of health.

HIV Community Services - Care

EIS- PLWH Provision of 1) Targeted HIV testing to help the

unaware learn of their HIV status and receive

referral to HIV care and treatment services if

found to be HIV-infected; 2) Referral services to

improve HIV care and treatment services; 3)

Access and linkage to HIV care and treatment

services; and 4) Outreach services and health

education/risk reduction (HE/RR) related to HIV

diagnosis.

Agency must enter data into the

approved DOH data system for

each consumer receiving Early

Intervention Services within 48

business hours from the time of

Client Intake.

Quarterly Reports are Required -

Deliverables for this reporting

period have been identified and

can be referenced in your

Quarterly Report Grid.

Agency must adhere to DOH

ID Reporting Requirements

Meeting/Event Summary

Forms should be submitted

with A19s.

$41,749 – MI 12618595 –

Local Proviso

$41,749 for 07/01/19-06/30/20

Case

Management

Provision of a range of client-centered

activities focused on improving health

outcomes in support of the HIV care

continuum. Includes all types of case

management encounters with or on behalf of

client (face-to-face, phone contact, any other

forms of communication). Activities may

include: 1) initial assessment of need;

2) development of individualized care plan;

3) coordinated access to health and support

services; 4) client monitoring to assess the

care plan; 5) re-evaluation of the care plan;

6) ongoing assessment of client's needs;

7) treatment adherence counseling; 8) client

specific advocacy or review of utilization of

services; 9) benefits counseling.

Agency must create a file in the

DOH approved data system for

each PLWH receiving Case

Management services within 48

business hours from the time of

Client Intake.

Agency must update

Demographics, Annual Review,

Services, Case Notes, Encounter

Tab and all requisite Custom Tabs

in the DOH approved data

system, as appropriate, within five

(5) business days from Client

Interaction or on behalf of Client

Agency must Track and report

within the DOH-approved data

system any and all Performance

Measures related to this Service

Category as directed by DOH

Quality Team.





$327,420 $245,565 – MI

1261859C –

Local Rebates

$327,420 $245,565 for 07/01/19-

03/31/20

$109,141 $81,856 – MI

1261850C–

Local Rebates

$109,141 $81,856 for 04/01/20-

06/30/20

$109,140 – MI 12615293 –

RW Supp Direct Svcs

$109,140 for 09/30/19-06/30/20


AMENDMENT #12




Amount

can be referenced in LHJ’s


Medical

Transportation

Provision of non-emergency transportation

services that enable an eligible client to access

or be retained in medical and support services.

May be provided by: 1) providers of

transportation services; 2) mileage

reimbursement (non-cash) that does not

exceed the established rates for federal

programs; 3) organization and use of

volunteer drivers through programs with

insurance and other liability issues specifically

addressed; 4) voucher or token systems.

Agency must track and report


system any and all activity

related to this Service Category.







$3,375 – MI 1261859C –

Local Rebates

$3,375 for 07/01/19-03/31/20

$1,125 – MI 1261850C–

Local Rebates

$1,125 for 04/01/20-06/30/20

Food Bank Provision of actual food items, hot meals, or a

voucher program to purchase food. This also

includes providing essential non-food items

(limited to personal hygiene products, household

cleaning supplies, and water filtration in

communities where issues of water safety exist).




related to this Service Category







$11,229 – MI 1261859C –

Local Rebates

$11,229 for 07/01/19-03/31/20

$3,743 – MI 1261850C–

Local Rebates

$3,743 for 04/01/20-06/30/20

Housing Provision of limited short-term assistance to

support emergency, temporary, or transitional

housing to enable a client or family to gain or

maintain health services. Housing-related

referral services include assessment, search,

placement, advocacy, and the fees associated

with these services. Housing services are

accompanied by a strategy to identify,

relocate, or ensure the client is moved to, or

capable of maintaining a long-term, stable

living situation. Housing must be linked to

client gaining or maintaining compliance with

HIV-related health services and treatment.


within the DOH approved data


related to this Service Category






ID Reporting Requirements $6,413 – MI 1261859C –

Local Rebates

$6,413 for 07/01/19-03/31/20

$2,137 – MI 1261850C–

Local Rebates

$2,137 for 04/01/20-06/30/20

Space and

Staff

LJH will provide necessary clinic space to

accommodate the provision of medical care to

HIV-positive individuals one (1) day per week

and an additional day every other week by a

physician from Harborview Medical Center;

LHJ shall inform prospective

patients of available medical care

through notification by HIV case

managers and other

announcements as determined by

Annual Narrative Report

describing

successes/challenges,

suggestions for changes/

improvements due June 30,

2020.

$91,728 – MI 12618590 –

Rebates

$91,728 for 07/01/19-06/30/20


AMENDMENT #12




Amount

Registered Nurse to assist physician and

administrative support staff to assist with project

Harborview Medical

Center and the LHJ.





Special Requirements

Federal Funding Accountability and Transparency Act (FFATA)

This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).

The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.

To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Data Universal Numbering System (DUNS®) number.

Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-282.


1. Definitions

CONTRACTOR – Entity receiving funds directly from Washington State Department of Health (DOH) to provide services for people at high risk (PAHR) and /or persons

living with HIV (PLWH).

2. Client Eligibility and Certification - Reference pages 15-17 in the HIV Community Services (HCS) Manual.

3. Title XIX HIV Medical Case Management – Reference pages 42-43 in the HCS Manual.

4. Quality Management/Improvement Activities – Reference pages 132-135 in the HCS Manual.

5. HIV Statewide Data System – Reference pages 136-144 in the HCS Manual.

6. HIV and STD Testing Services

a. HIV testing services must follow DOH and Centers for Disease Control and Prevention (CDC) guidance for HIV testing.

b. Persons found to be sero-positive must be provided with partner services (PS) that follow current CDC guidelines for HIV PS and DOH HIV Partner Services Standards.

Contractors must refer newly identified HIV infected persons to the local health jurisdiction for PS.

c. Any funds generated from charging clients for HIV testing must be used to support or enhance HIV prevention activities.

d. HIV counseling/testing must be performed by personnel who have completed DOH-approved training. Staff providing testing services must also attend and complete

any additional training as determined necessary by DOH.



https://www.usaspending.gov/#/

AMENDMENT #12



e. Persons performing HIV testing must be authorized by a licensed provider whose scope of practice includes ordering of diagnostic tests. This can be achieved with

memorandum of understanding / agreement (MOU/A) between agencies if there is no licensed provider directly accountable to the contracted agency. Persons

performing HIV testing must obtain all necessary and required Washington State certification.

f. Contractor will present confidential HIV testing as the default option for all persons tested. If an anonymous test is performed, refusal by the client for confidential

testing must be documented and permission by the client for conversion to confidential testing in the event of a reactive result must be obtained prior to the test being

provided.

g. Contractor must report all reactive results to DOH using the Preliminary Positive Reporting Form (provided by DOH). The information on this form allows DOH to

determine whether the preliminary result is confirmed by subsequent testing and if the person diagnosed with HIV is linked to medical care and complete data entry in

Evaluation Web. Preliminary Positive Reports must be submitted to DOH directly, not local public health departments by confidential transmittal as indicated on the form.

h. Contractor will ensure that sufficient staff is available to perform HIV testing using capillary and/or venous draws.

7. Reporting Requirements – Reference page 26 in the HCS Manual. Deliverables grid will have identified contract.

8. Training requirements – Reference pages 29-30 in the HCS Manual.

9. Participation in Washington State’s HIV Planning Process – Reference page 10-11 in the HCS Manual.

10. Participation in End AIDS Washington Initiative The End AIDS Washington Initiative is a collaboration of community-based organizations (CBOs), government agencies and education and research institutions working

together to reduce the rate of new HIV infections in Washington by 50% by 2020. The End AIDS Washington initiative and the forthcoming implementation plan are not

owned by any one government agency or CBO. End AIDS Washington is a community-owned effort and will only be successful if all stakeholders—communities,

government, the health care system, and people most affected by HIV—are fully engaged in its implementation efforts and empowered to make decisions and set priorities.

11. Participation in End AIDS Washington Statewide Media Campaign

The End AIDS Washington Statewide Media Campaign effort aims to promote the priorities laid out in the EAW Initiative around the state through various ways. Funded

agencies will ensure the participation of at least one staff member funded through PAHR Services in End AIDS Washington Campaign related activities including, but not

limited to, the End AIDS Washington Champions program. Funded agencies will, whenever possible, utilize End AIDS Washington messaging and branding on educational

and outreach materials.

12. Contract Management – Reference pages 32-48 in the HCS Manual.

a. Fiscal Guidance

i) Funding –The CONTRACTOR shall submit all claims for payment for costs due and payable under this statement of work by July 25, 2020. DOH will pay belated

claims at its discretion, contingent upon the availability of funds.

ii) The CONTRACTOR agrees to reimburse DOH for expenditures billed to the DOH for costs that are later determined through audit or monitoring to be disallowed

under the requirements of 2 CFR Part 200 –Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Audits.

iii) Submission of Invoice Vouchers – On a monthly basis, the CONTRACTOR shall submit correct A19-1A invoice vouchers amounts billable to DOH under this

statement of work. All A19-1A invoice vouchers must be submitted by the 25th of the following month.

iv) Advance Payments Prohibited – Reference page 32 in the HCS Manual.

v) Payer of Last Resort – Reference page 44 in the HCS Manual.

vi) Cost of Services – Reference page 32 in the HCS Manual.


AMENDMENT #12



vii) Emergency Financial Assistance –The CONTRACTOR shall not use contract funds to provide a parallel medication service to EIP. CONTRACTOR’s providing

case management services shall make every effort to enroll clients in EIP.

viii) Payment of Cash or Checks to Clients Not Allowed – Where direct provision of service is not possible or effective, vouchers or similar programs, which may

only be exchanged for a specific service (e.g., transportation), shall be used to meet the need for such services. CONTRACTOR shall administer voucher programs

to assure that recipients cannot readily convert vouchers into cash.

ix) Funds for Needle Exchange Programs Not Allowed using Federal or Rebate dollars – CONTRACTOR shall not expend contract funds to support needle

exchange programs.

x) Supervision, under DOH Community Programs contracts, will be understood as the delivery of a set of interrelated functions encompassing administrative,

educational and supportive roles that work collectively to ensure clinical staff (i.e. case managers, navigators, coordinators, assistants, coaches) are equipped with

the skills necessary to deliver competent and ethical services to clients that adhere to best practices within applicable fields as well as all relevant Statewide

Standards. Supervisors must meet the criteria set forth within the WA State HIV Case Management Standards and provide the level of interaction and review

detailed in that document.

It is the understanding of DOH that Supervision funded under the direct program portion of this contract include at minimum the provision of at least two of the

three functions detailed here: administrative, educational or supportive supervision. Supervision that encompasses only administrative functions will not be

considered billable under Direct Program. To that end, it is the expectation of DOH that those personnel identified as Supervisors have no more than one degree of

separation from direct client care. Exceptions to this rule can be presented and considered to and by DOH Contract Management. It will fall to the requesting

organization to satisfactorily demonstrate that any Supervisory positions falling within the scope of Direct Program are meeting the expectation of provision of

educational or supportive supervision with the aim of directly impacting client experiences, quality of services, and adherence to best practices and Statewide

Standards.

b. Contract Modifications

i) Notice of Change in Services – The CONTRACTOR shall notify DOH program staff, within 45 days, if any situations arise that may impede implementation of

the services contained in the statement of work. DOH and the CONTRACTOR will agree to strategies for resolving any shortfalls. DOH retains the right to

withhold funds in the event of substantial noncompliance.

c. Subcontracting

i) This statement of work does not allow a CONTRACTOR to subcontract for services.

d. Written Agreements

i) The CONTRACTOR should execute written agreements with the providers listed below to document how the providers’ services and activities will be

coordinated with funded Medical HIV Case Management services and activities:

(1) Partner Counseling and Re-Linkage Services (PCRS)

(2) HIV Testing Services

(3) Medical Providers providing services to agency’s medical case management clients

(4) Other Local Health Jurisdictions in the counties regularly served by the CONTRACTOR Technical assistance is available through DOH.


AMENDMENT #12



13. Material Review and Website Disclaimer Notice

In accordance with all federal guidance, contractors receiving funds through this RFA will:

a. Submit all proposed written materials including, but not limited to, pictorials, audiovisuals, questionnaires, survey instruments, agendas for conferences, plans for

educational sessions, and client satisfaction surveys purchased, produced, or used by staff funded with DOH funds to the State HIV/AIDS Materials Review

Committee. CONTRACTOR shall submit all materials to be reviewed to:

Michael Barnes, Washington State Department of Health

PO Box 47840, Olympia, WA 98504-7841

Phone: (360) 810-1880/Fax: (360) 664-2216

Email: [email protected]

b. Assure prominent display of disclaimer notice on all websites containing HIV/AIDS education information (including subcontractors). Such notice must consist of

language similar to the following: “This site contains HIV prevention messages that may not be appropriate for all audiences. Since HIV infection is spread primarily

through sexual practices or by sharing needles, prevention messages and programs may address these topics. If you are not seeking such information or may be offended

by such materials, please exit this website.”

14. Youth and Peer Outreach Workers

For purposes of this agreement, the term “youth” applies to persons under the age of 18. All programs, including subcontractors, using youth (either paid or volunteer) in

program activities will use caution and judgment in the venues / situations where youth workers are placed. Agencies will give careful consideration to the age

appropriateness of the activity or venue; will ensure that youth comply with all relevant laws and regulations regarding entrance into adult establishments and environments;

and will implement appropriate safety protocols that include clear explanation of the appropriate laws and curfews and clearly delineate safe and appropriate participation of

youth in program outreach activities.

15. Confidentiality Requirements – Reference pages 18-19 in the HCS Manual.

16. Whistleblower

a. Whistleblower statute, 41 U.S.C. & 4712, applies to all employees working for CONTRACTOR, subcontractors, and subgrantees on federal grants and contracts. The

statute (41 U.S.C. & 4712) states that an “employee of a CONTRACTOR, subcontractor, grantee, or subgrantee, may not be discharged, demoted, or otherwise

discriminated against as a reprisal for “whistleblowing.” In addition, whistleblower protections cannot be waived by an agreement, policy, form, or condition of

employment.

b. The National Defense Authorization Act (NDAA) for Fiscal Year 2013 (Pub. L. 112-239, enacted January 2, 2013) mandates a pilot program entitled “Pilot Program

for Enhancement of Contractor Employee Whistleblower Protections.” This program requires all grantees, their subgrantees, and subcontractors to:

i. Inform their employees working on any federal award they are subject to the whistleblower rights and remedies of the pilot program;

ii. Inform their employees in writing of employee whistleblower protections under 41 U.S.C. & 4712 in the predominant native language of the workforce; and;

iii. CONTRACTOR and grantees will include such requirements in any agreement made with a subcontractor or subgrantee.

17. Allowable Costs

All expenditures incurred and reimbursements made for performance under this statement of work shall be based on actual allowable costs. Costs can include direct labor,

direct material, and other direct costs specific to the performance of activities or achievement of deliverables under this statement of work.

For information in determining allowable costs, please reference OMB Circulars:

2 CFR200 (State, Local and Indian Tribal governments) at: https://www.federalregister.gov/documents/2013/12/26/2013- 30465/uniform-administrative-requirements-

cost-principles-and-audit-requirements-for-federal-awards



https://www.federalregister.gov/documents/2013/12/26/2013-30465/uniform-administrative-requirements-cost-principles-and-audit-requirements-for-federal-awards



AMENDMENT #12



**Disclosure of information is governed by the Washington Administrative Code (WAC) 246-101-120, 520 and 635, and the Revised Code of Washington (RCW) 70.24.080,

70.24.084, and 70.24.105 regarding the exchange of medical information among health care providers related to HIV/AIDS or STD diagnosis and treatment. Please note that

CONTRACTORs fit under the definition of “health care providers” and “individuals with knowledge of a person with a reportable disease or condition” in the WAC and RCW.

DOH statutory authority to have access to the confidential information or limited Dataset(s) identified in this agreement to the Informat ion Recipient: RCW 43.70.050

Information Recipient’s statutory authority to receive the confidential information or limited Dataset(s) identified in this Agreement: RCW 70.02.220 (7)

DOH Program Contact, PLWH DOH Program Contact, SSP DOH Fiscal Contact

Chris Wukasch Sarah Deutsch Abby Gilliland

DOH, HIV Client Services DOH, Infectious Disease Prevention DOH, Infectious Disease Operations Unit

PO Box 47841, Olympia, WA 98504-7841 PO Box 47840, Olympia, WA 98504-7841 PO Box 47840, Olympia, WA 98504-7841

360-236-3429/Fax: 360-664-2216 360-236-3579/Fax: 360-664-2216 360-236-3351/Fax: 360-664-2216

[email protected] [email protected] [email protected]




AMENDMENT #12



Exhibit A

Statement of Work


DOH Program Name or Title: Office of Drinking Water Group A Program -

Effective January 1, 2018




Federal Contractor

State

Other

Federal Compliance




Type of Payment

Reimbursement

Fixed Price Period of Performance: January 1, 2018 through December 31, 2020

Statement of Work Purpose: The purpose of this statement of work is to provide funding to the LHJ for conducting sanitary surveys and providing technical assistance to small

community and non-community Group A water systems.

Revision Purpose: The purpose of this revision is to extend funding periods from 12/31/19 to 12/31/20 for Yr22 SRF SS and TA, increase Total Consideration to incorporate

2020 SS and TA, and revise Special Billing Requirements and Special Instructions.


Revenue

Code

Master

Index

Code

Funding

(LHJ Use

Start Date

Period

Only)

End Date

Current

Consideration

Change

Increase (+)

Total

Consideration

Yr 20 SRF - Local Asst (15%) (FS) SS N/A 346.26.64 24139220 01/01/18 12/31/18 0 0 0

Yr 20 SRF - Local Asst (15%) (FS) TA N/A 346.26.66 24139220 01/01/18 12/31/18 0 0 0

Yr 20 SRF - Prog Mgmt (10%) (FS) TA N/A 346.26.66 24137220 01/01/18 12/31/18 1,268 0 1,268

Yr 21 SRF - Local Asst (15%) (FS) SS N/A 346.26.64 24139221 01/01/18 06/30/19 14,250 0 14,250

Yr 21 SRF - Local Asst (15%) (FS) TA N/A 346.26.66 24139221 01/01/18 06/30/19 1,900 0 1,900

Yr 22 SRF - Local Asst (15%) (FO-SW) SS N/A 346.26.64 24239222 01/01/19 12/31/20 12,750 8,500 21,250

Yr 22 SRF - Local Asst (15%) (FO-SW) TA N/A 346.26.66 24239222 01/01/19 12/31/20 1,249 3,000 4,249

TOTALS 31,417 11,500 42,917

Task


*May Support PHAB


Due Date/Time

Frame

Payment Information and/or

Amount

1 Trained LHJ staff will conduct

sanitary surveys of small community

and non-community Group A water

systems identified by the DOH Office

of Drinking Water (ODW) Regional

Office.

See Special Instructions for task

activity.

Provide Final* Sanitary

Survey Reports to ODW

Regional Office. Complete

Sanitary Survey Reports shall

include:

1. Cover letter identifying

significant deficiencies,

significant findings,

observations,

recommendations, and

Final Sanitary Survey

Reports must be

received by the ODW

Regional Office within

30 calendar days of

conducting the

sanitary survey.

Upon ODW acceptance of the Final

Sanitary Survey Report, the LHJ shall

be paid $250 for each sanitary survey

of a non-community system with three

or fewer connections.

Upon ODW acceptance of the Final

Sanitary Survey Report, the LHJ shall

be paid $500 for each sanitary survey

of a non-community system with four


AMENDMENT #12



Task


*May Support PHAB


Due Date/Time

Frame


Amount

DOH will provide a tablet and GPS

unit for the LHJ to gather source data

during a routine sanitary survey. DOH

expects the LHJ to commit to using

the tablet and GPS for a five-year

period.

referrals for further

ODW follow-up.

2. Completed Small Water

System checklist.

3. Updated Water Facilities

Inventory (WFI).

4. Photos of water system

with text identifying

features

5. Any other supporting

documents.

*Final Reports reviewed and

accepted by the ODW

Regional Office.

The LHJ surveyor will record

at least two (2) GPS data

points, for each source, into

the preloaded Excel template

on the tablet and submit that

data file with the associated

sanitary survey.

or more connections and each

community system.

Payment is inclusive of all associated

costs such as travel, lodging, per diem.

Payment is authorized upon receipt and

acceptance of the Final Sanitary

Survey Report within the 30 day

deadline.

Late or incomplete reports may not be

accepted for payment.

2 Trained LHJ staff will conduct

Special Purpose Investigations (SPI)

of small community and non-

community Group A water systems

identified by the ODW Regional

Office.


activity.

Provide completed SPI

Report and any supporting

documents and photos to

ODW Regional Office.

Completed SPI

Reports must be

received by the ODW

Regional Office within

2 working days of the

service request.

Upon acceptance of the completed SPI

Report, the LHJ shall be paid $800 for

each SPI.


costs such as travel, lodging, per diem.


acceptance of completed SPI Report

within the 2 working day deadline.




AMENDMENT #12



Task


*May Support PHAB


Due Date/Time

Frame


Amount

3 Trained LHJ staff will provide direct

technical assistance (TA) to small

community and non-community

Group A water systems identified by

the ODW Regional Office.


activity.

Provide completed TA

Report and any supporting

documents and photos to

ODW Regional Office.

Completed TA Report

must be received by

the ODW Regional

Office within 30

calendar days of

providing technical

assistance.

Upon acceptance of the completed TA

Report, the LHJ shall be paid for each

technical assistance activity as follows:

Up to 3 hours of work: $250

3-6 hours of work: $500

More than 6 hours of work: $750


costs such as consulting fee, travel,

lodging, per diem.


acceptance of completed TA Report

within the 30-day deadline.



4 LHJ staff performing the activities

under tasks 1, 2 and 3 must have

completed the mandatory Sanitary

Survey Training.


activity.

Prior to attending the

training, submit an

“Authorization for Travel

(Non-Employee)” DOH

Form 710-013 to the ODW

Program Contact below for

approval (to ensure that

enough funds are available).

Annually LHJ shall be paid mileage, per diem,

lodging, and registration costs as

approved on the pre-authorization form

in accordance with the current rates

listed on the OFM Website

http://www.ofm.wa.gov/resources/trav

el.asp






Special References (RCWs, WACs, etc)

Chapter 246-290 WAC is the set of rules that regulate Group A water systems. By this statement of work, ODW contracts with the LHJ to conduct sanitary surveys (and SPIs, and

provide technical assistance) for small community and non-community water systems with groundwater sources. ODW retains responsibility for conducting sanitary surveys (and

SPIs, and provide technical assistance) for small community and non-community water systems with surface water sources, large water systems, and systems with complex

treatment.

LHJ staff assigned to perform activities under tasks 1, 2, and 3 must be trained and approved by ODW prior to performing work. See special instructions under Task 4, below.


http://www.ofm.wa.gov/resources/travel.asp

http://www.ofm.wa.gov/resources/travel.asp


AMENDMENT #12



Special Billing Requirements

The LHJ shall submit quarterly invoices within 30 days following the end of the quarter in which work was completed, noting on the invoice the quarter and year being billed for.

Payment cannot exceed a maximum accumulative fee of $27,000 $35,500 for Task 1, and $4,417 $7,417 for Task 2, Task 3 and Task 4 combined during the contracting period,

to be paid at the rates specified in the Payment Method/Amount section above.

When invoicing for Task 1, submit the list of WS Name, ID #, Amount Billed, Survey Date and Letter Date that you are requesting payment.

When invoicing for Task 2-3, submit the list of WS Name, ID #, TA Date and description of TA work performed, and Amount Billed.

When invoicing for Task 4, submit receipts and the signed pre-authorization form for non-employee travel to the ODW Program Contact below and a signed A19-1A Invoice

Voucher to the DOH Grants Management, billing to BARS Revenue Code 346.26.66 under Technical Assistance (TA).

Special Instructions

Task 1

Trained LHJ staff will evaluate the water system for physical and operational deficiencies and prepare a Final Sanitary Survey Report which has been accepted by ODW. Detailed

guidance is provided in the Field Guide for Sanitary Surveys, Special Purpose Investigations and Technical Assistance (Field Guide). The sanitary survey will include an

evaluation of the following eight elements: source; treatment; distribution system; finished water storage; pumps, pump facilities and controls; monitoring, reporting and data

verification; system management and operation; and certified operator compliance. If a system is more complex than anticipated or other significant issues arise, the LHJ may

request ODW assistance.

No more than 3 surveys of non-community systems with three or fewer connections to be completed between January 1, 2018 and December 31, 2018.

No more than 27 surveys of non-community systems with four or more connections and all community systems to be completed between January 1, 2018 and

December 31, 2018.



December 31, 2019.



December 31, 2020.

The process for assignment of surveys to the LHJ, notification of the water system, and ODW follow-up with unresponsive water systems; and other roles and responsibilities of

the LHJ are described in the Field Guide.

Task 2

Trained LHJ staff will perform Special Purpose Investigations (SPIs) as assigned by ODW. SPIs are inspections to determine the cause of positive coliform samples or the cause of

other emergency conditions. SPIs may also include sanitary surveys of newly discovered Group A water systems. Additional detail about conducting SPIs is described in the Field

Guide. The ODW Regional Office must authorize in advance any SPI conducted by LHJ staff.

Task 3

Trained LHJ staff will conduct Technical assistance as assigned by ODW. Technical Assistance includes assisting water system personnel in completing work or verifying work

has been addressed as required, requested, or advised by the ODW to meet applicable drinking water regulations. Examples of technical assistance activities are described in the

Field Guide. The ODW Regional Office must authorize in advance any technical assistance provided by the LHJ to a water system.

Task 4

LHJ staff assigned to perform activities under tasks 1, 2, and 3 must be trained and approved by ODW prior to performing work. LHJ staff performing the activities under tasks 1,

2 and 3 must have completed, with a passing score, the ODW Online Sanitary Survey Training and the ODW Sanitary Survey Field Training. LHJ staff performing activities under

tasks 1, 2, and 3 must attend the Annual ODW Sanitary Survey Workshop, and are expected to attend the Regional ODW LHJ Drinking Water Meetings.


http://dohweb.doh.wa.lcl/OFS/FinancialServicesWeb/TravelWeb/Glossary.htm#Receipts__

AMENDMENT #12



If required trainings, workshops or meetings are not available, not scheduled, or if the LHJ staff person is unable to attend these activities prior to conducting assigned tasks, the

LHJ staff person may, with ODW approval, substitute other training activities to be determined by ODW. Such substitute activities may include one-on-one training with ODW

staff, co-surveys with ODW staff, or other activities as arranged and pre-approved by ODW. LHJ staff may not perform the activities under tasks 1, 2, and 3 without completing

the training that has been arranged and approved by ODW.

Program Manual, Handbook, Policy References

http://www.doh.wa.gov/Portals/1/Documents/Pubs/331-486.pdf

DOH Program Contact DOH Fiscal Contact

Denise Miles Karena McGovern

DOH Office of Drinking Water DOH Office of Drinking Water

243 Israel Rd SE 243 Israel Rd SE

Tumwater, WA 98501 Tumwater, WA 98501

[email protected] [email protected]

(360) 236-3028 (360) 236-3094


http://www.doh.wa.gov/Portals/1/Documents/Pubs/331-486.pdf



AMENDMENT #12



Exhibit A

Statement of Work


DOH Program Name or Title: Office of Emergency Preparedness & Response -





Federal Subrecipient

State

Other

Federal Compliance




Type of Payment

Reimbursement


Statement of Work Purpose: The purpose of this statement of work is to establish the funding and tasks for the Public Health Emergency Preparedness and Response program

for the 2019 grant period.

Revision Purpose: The purpose of this revision is to add regional or statewide to scope of emergency preparedness events to be attended, spell out acronyms, update several

deliverables and due dates to match activities, clarify health care coalition participation and deliverable, and update DOH contact information.


Revenue

Code

Master

Index

Code

Funding

(LHJ Use

Start Date

Period

Only)

End Date

Current

Consideration

Change

None

Total

Consideration

FFY19 PHEP BP1 LHJ FUNDING 93.069 333.93.06 31102190 07/01/19 06/30/20 295,345 0 295,345

TOTALS 295,345 0 295,345

Task


*May Support PHAB


Due Date/Time

Frame

Payment

Information and/or

Amount

1 Attend emergency preparedness events, (e.g.

trainings, meetings, conference calls, and

conferences) to advance LHJ regional or statewide

preparedness or complete the deliverables in this

statement of work.

Submit summary on the mid-year

and end of year progress report.

December 31, 2019

and June 30, 2020

Reimbursement for

actual costs not to

exceed total funding

consideration amount

2 Complete reporting templates as requested by

DOH to comply with program and federal grant

requirements including gap analysis, mid-year

report and end-of-year report.

Submit completed templates to

DOH.

Upon request

3 Complete all performance measure reporting

requirements as requested by DOH.

Submit completed performance

measure data.

Upon request


AMENDMENT #12



Task


*May Support PHAB


Due Date/Time

Frame

Payment

Information and/or

Amount

4 Training:

4.1) Provide training for appropriate staff who

serve in the Emergency Operations Center (EOC)

and the Emergency Support Function #8: Public

Health and Medical Services (ESF#8) role on the

Incident Command System, ESF#8 response plans

and policies.

4.2) Train appropriate public health emergency

response staff on Web EOC or applicable

information management system utilized by the

local health department

Submit mid-year and end-of-year

progress reports.

Provide sign in sheets of trainings

conducted, with attendee

signatures and contact information.

or registrations if training is

conducted by an entity other than

the LHJ. If DOH, or a DOH

Contractor, is providing the

training, LHJ does not need to

submit sign in sheets.

December 31, 2019

and June 30, 2020

Upon completion of

training, but no later

than June 30, 2020

5 Washington Secure Electronic Communication,

Urgent Response and Exchange System

(WASECURES):

5.1) Maintain WASECURES program as the

primary emergency notification system within the

LHJ for receiving alerts from DOH, and include all

critical LHJ positions as registered users.

5.2) Participate in DOH-led WASECURES

notification drills

5.3) Conduct a notification drill using LHJ’s

preferred staff notification system.

Notes: Registered users must log in quarterly at a

minimum. DOH will provide on-site technical

assistance to LHJs on utilizing WASECURES.

LHJs may choose to utilize other notification

systems in addition to WASECURES to alert staff

during incidents.

Submit mid-year and end of year

progress reports.

A list of registered users with their

title and role in the emergency

response plan.

Submit results of notification drills

conducted or participated in.

December 31, 2019

and June 30, 2020

December 31, 2019

Within one week of

the drill, but no later

than June 30, 2020


AMENDMENT #12



Task


*May Support PHAB


Due Date/Time

Frame

Payment

Information and/or

Amount

6 Communications:

6.1) Participate in at least one risk

communications webinar hosted by DOH.

Webinars will be offered twice; one in the first half

of the budget period and one in the second half of

the budget period.

6.2) Participate in DOH Public Information Officer

Workgroup.

6.3) Participate in at least one risk

communications drill conducted by DOH. Drill

will occur via webinar, conference call, and email.

Drill will test LHJ’s ability to develop and

disseminate key messages via social media, email

to community partners, phone trees, newsletters,

and other means preferred by the LHJ.

6.4) Produce an after action report (AAR)

evaluating LHJ participation in the drill.

6.4) Conduct a hot wash evaluating LHJ

participation in the drill.

6.5) Participation in a real-world incident will

satisfy the need to participate in a communications

drill.


progress reports.

Submit messaging used to inform

the public during drills, including a

summary of how communication

tools were used.

Submit After Action Reports

(AARs).

Submit documentation of items

identified in hot wash in mid-year

and end of year reports.

Submit documentation of

participation in incident including

communication methods and tools

used. Submit AAR.

December 31, 2019

and June 30, 2020

Within 90 days of

drill, but no later than

June 30, 2020

Within 90 days of the

drill, but no later than

June 30, 2020

December 31, 2019

and June 30, 2020

Within 90 days of the

end of the incident,

but no later than

June 30, 2020

7 Non-CRI LHJs:

Update plans to request, receive, and dispense

medical countermeasures. Plans should include the

addresses of all local public Points of Dispensing

(PODs) (not including pharmacies or healthcare

facilities), sources of public POD staffing, local

receiving and pickup sites (Hubs) identified by the

LHJ, and whether the LHJ intends to pick

countermeasures from DOH.

Note: LHJs are not required to maintain a HUB;

LHJs may partner with other organizations to

centralize distribution.


progress reports.

Submit updated plan to request,

receive and dispense medical

countermeasures.

December 31, 2019

and June 30, 2020

June 30, 2020


AMENDMENT #12



Task


*May Support PHAB


Due Date/Time

Frame

Payment

Information and/or

Amount

8 Provide immediate notification to the DOH Duty

Officer at 360-888-0838 or [email protected]

for all response incidents involving utilization of

emergency response plans and structures.


progress reports including

documentation that notification to

DOH was provided; or statement

that no incident response occurred.

Send notification to DOH Duty

Officer.

December 31, 2019

and June 30, 2020

As soon as possible

(performance measure

target is within 60

minutes)

9 Produce and provide situation reports documenting

LHJ activity to DOH during all incidents involving

an emergency response or activation by the LHJ.

Situation reports may be developed by the LHJ, or

may be jurisdictional situation reports that include

input from the LHJ.

Submit situation reports to DOH

Duty Officer by email to

[email protected].


progress reports to include

situation reports demonstrating

DOH was notified of incident

response, or statement that no

incident response occurred.

Upon completion

December 31, 2019

and June 30, 2020

10 Provide Essential Elements of Information (EEIs)

during incident response upon request by DOH.

Note: DOH will convey requests for specific data

elements (EEIs) to the LHJ during an incident.

Provide essential elements of

information upon request.

Upon request

11 Attend regional Health Care Coalition (HCC)

district meetings as requested by HCC Lead and

deemed appropriate by LHJ.


progress reports documenting

participation in meetings.

December 31, 2019

and June 30, 2020

12 Participate in development of Disaster Clinical

Advisory Committee (DCAC) meetings as

appropriate. May include identifying local clinical

participants, attending meetings via webinar and

reviewing planning efforts.



participation in DCAC.

December 31, 2019

and June 30, 2020

13 Participate in at least one HCC drill and/or

exercise to include, but not limited to: redundant

communications, WATrac, Coalition Surge Test

(CST), or other drills and exercises to support

planning and response efforts inclusive of public

health and/or ESF8.



participation in drills/exercises.

December 31, 2019

and June 30, 2020

14 Actively participate in discussions pertaining to

Emergency Support Function #8 (ESF8) and HCC


progress reports.

December 31, 2019

and June 30, 2020




AMENDMENT #12



Task


*May Support PHAB


Due Date/Time

Frame

Payment

Information and/or

Amount

roles and responsibilities, as requested by HCC

Lead and deemed appropriate by LHJ.

15 Participate in HCC planning process to update

plans by reviewing coalition plans for alignment

with local ESF8 plans.


progress reports.

December 31, 2019

and June 30, 2020

16 Coordinate with HCC during responses involving

healthcare organizations within your jurisdiction.

If no response occurred, document that in mid-year

and end of year progress reports.


progress reports.

December 31, 2019

and June 30, 2020

11 Regional Health Care Coalition (HCC),

participate in:

- Regional HCC district meetings as requested

by HCC Lead and deemed appropriate by

LHJ.

- Development of Disaster Clinical Advisory

Committee (DCAC) meetings as appropriate.

May include identifying local clinical

participants, attending meetings via webinar

and reviewing planning efforts.

- At least one HCC drill and/or exercise to

include, but not limited to: redundant

communications, WATrac, Coalition Surge

Test (CST), or other drills and exercises to

support planning and response efforts

inclusive of public health and/or Emergency

Support Function 8: Public Health and

Medical Services (ESF8).

- Discussions pertaining to ESF8 and HCC

roles and responsibilities, as requested by

HCC Lead and deemed appropriate by

LHJ.

- Reviewing HCC plans for alignment with

local ESF8 plans.

- Coordination with HCC during responses

involving healthcare organizations within

your jurisdiction. If no response occurred,

document that in mid-year and end of year

progress reports.



activities.

December 31, 2019

and June 30, 2020


AMENDMENT #12



Task


*May Support PHAB


Due Date/Time

Frame

Payment

Information and/or

Amount

17

12

Participate in one or more exercises or real world

incidents testing each of the following:

The process for requesting and receiving

resource support

The process for gaining and maintaining

situational awareness of, at a minimum:

o The functionality of critical public health

operations

o The functionality of critical healthcare

facilities and the services they provide

o The functionality of critical infrastructure

serving public health and healthcare

facilities (roads, water, sewer, power,

communications)

o Number of disease cases

o Number of fatalities attributed to an

incident

o Development of an ESF8 situation

report, or compilation of situational

awareness information to be included in a

County situation report

o Emergency Operations Center (EOC) or

Incident Command System (ICS)

activation


progress reports.

Submit After Action Reviews

(AARs) and Corrective Action

Plan (CAP) for each

drill/exercise/incident conducted

or participated in.

December 31, 2019

and June 30, 2020

Within 60 days of

completion of

exercise/incident, but

no later than June 30,

2020

18

13

Vulnerable populations:

18.1) Update and maintain the All Hazards Plan to

address vulnerable populations.

18.2) Provide a procedure, checklist, job action

sheet, or other document(s) that describe how the

needs of vulnerable populations (especially those

with access and functional needs) will be addressed

during a response. The document(s) should also

describe how the LHJ will engage directly with the

affected populations during a response.

18.3) Document the primary groups within the LHJ

boundaries identified in Centers for Disease

Control and Prevention (CDC)’s Social

Vulnerability Index to inform public health

response planning.


progress reports.

Submit updated sections of the All

Hazards Plan.

Submit procedure checklist, job

action sheet or other

documentation.

Documentation of primary

vulnerable population groups.

December 31, 2019

and June 30, 2020

June 30, 2020

June 30, 2020

June 30, 2020


AMENDMENT #12



Task


*May Support PHAB


Due Date/Time

Frame

Payment

Information and/or

Amount

19

14

Update and maintain logistical support plans for

individuals placed into isolation or quarantine (this

need not include identification of quarantine

facilities). Plans must meet requirements defined

in Washington Administrative Code (WAC)

246.100.045.


progress reports.

Submit logistical isolation and

quarantine plan.

December 31, 2019

and June 30, 2020

June 30, 2020

20

15

Develop and maintain agreements with facilities

within the region that could serve as an Alternate

Care Facility (ACF) or a Federal Medical Station

(FMS).


progress reports.

List of facilities and copies of

current agreements.

December 31, 2019

and June 30, 2020

June 30, 2020

21

16

Develop and maintain specific vendor lists for

logistical support services for Alternate Care

Facilities (ACFs) or Federal Medical Station

(FMS) operations including at a minimum:

Biohazard/Waste Management

Feeding

Laundry

Communications

Sanitation


progress reports

Vendor lists for the support

services listed.

December 31, 2019

and June 30, 2020

December 31, 2019

22

17

Update and maintain public health preparedness

training and exercise plan.

Submit updated training and

exercise plan.

December 31, 2019

23

18

Complete an evaluation of your response

capabilities based on a standard evaluation tool

provided by DOH.

Document evaluation participation

in the mid-year and end of year

progress reports.

December 31, 2019

and June 30, 2020

24

19

Produce a budget plan including a detailed 12-

month spending plan demonstrating how the LHJ

plans to spend the funds during this period of

performance, using a budget template provided by

DOH.

Note: 20% of LHJ’s annual allocation will be

withheld until this requirement is met. Failure to

meet this requirement may result in DOH

redirecting funds from the LHJ.

Submit budget plan using DOH-

provided template.

August 1, 2019


AMENDMENT #12



Task


*May Support PHAB


Due Date/Time

Frame

Payment

Information and/or

Amount

Additional activities as requested by the LHJ:

25

20

Provide consultation and grant support to Clallam

and Jefferson Local Emergency Response

Coordinators (LERCs) as requested. Provide

consultation to DOH on behalf of Region 2 as

requested.


progress reports

December 31, 2019

and June 30, 2020

26

21

Maintain county and regional public health

emergency answering service and duty officer

program.

Costs will be pro-rated and shared equally with

Kitsap Public Health District Emergency

Preparedness, Community Health and

Environmental Health programs.


progress reports

December 31, 2019

and June 30, 2020

27

22

Update County Pandemic Influenza Plan based on

Center for Disease Control & Prevention guidance.


progress reports

Submit County Pandemic

Influenza Plan.

December 31, 2019

and June 30, 2020

June 30, 2020

28

23

Update County Emergency Support Function # 8

resource documents.


progress reports

Submit updated ESF 8 resource

documents.

December 31, 2019

and June 30, 2020

June 30, 2020

29

24

Review and update, as needed, LHJ’s response

plans, including:

All Hazards Emergency Response Plan

LHJ Continuity of Operations Plan

LHJ Risk Communications Plan


progress reports

Submit updated plans.

December 31, 2019

and June 30, 2020

June 30, 2020






Any subcontract/s must be approved by DOH prior to executing the contract/s.

Deliverables are to be submitted to the ConCon deliverables mailbox at [email protected]




AMENDMENT #12



Special Requirements

Federal Funding Accountability and Transparency Act (FFATA)

This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFATA or the Transparency Act).

The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent.

To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Data Universal Numbering System (DUNS®) number.

Information about the LHJ and this statement of work will be made available on USASpending.gov by DOH as required by P.L. 109-282.

Restrictions on Funds

Please reference the Code of Federal Regulations:

https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=58ffddb5363a27f26e9d12ccec462549&ty=HTML&h=L&mc=true&r=PART&n=pt2.1.200#se2.1.200_1439

DOH Program Contact

Karen Kenneson, Admin Operations Supervisor

Tory Henderson, Contracts & Finance Specialist

Department of Health

P O Box 47960, Olympia, WA 98504-7960

360-236-4075 / [email protected]

360-236-4596 / [email protected]


https://www.usaspending.gov/#/

https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=58ffddb5363a27f26e9d12ccec462549&ty=HTML&h=L&mc=true&r=PART&n=pt2.1.200#se2.1.200_1439



EXHIBIT B-12

Kitsap Public Health District ALLOCATIONS Contract Number: CLH18248

Contract Term: 2018-2020 Date: November 15, 2019

Indirect Rate as of January 2018: 34.98% Admin & Fac.; 37.62% Community Hlth Pgms (inc. Admin) & 40.39% Environmental Hlth Pgms (inc. Admin)


BARS Funding Chart of

Federal Award Revenue Period Accounts

Chart of Accounts Program Title Identification # Amend # CFDA* Code** Start Date End Date Start Date End Date Amount Sub Total Total

FFY20 CSS USDA FINI Prog Mgnt 20157001823357 Amd 8 10.331 333.10.33 10/01/19 03/31/20 10/01/19 03/31/20 ($13,410) $25,000 $145,847

FFY20 CSS USDA FINI Prog Mgnt 20157001823357 Amd 6 10.331 333.10.33 10/01/19 03/31/20 10/01/19 03/31/20 $38,410

FFY19 CSS USDA FINI Prog Mgnt 20157001823357 Amd 8 10.331 333.10.33 10/01/18 09/30/19 10/01/18 09/30/19 ($10,716) $78,347

FFY19 CSS USDA FINI Prog Mgnt 20157001823357 N/A 10.331 333.10.33 10/01/18 09/30/19 10/01/18 09/30/19 $89,063

FFY18 CSS USDA FINI Prog Mgnt 20157001823357 Amd 8 10.331 333.10.33 01/01/18 09/30/18 10/01/17 09/30/18 ($7,500) $42,500

FFY18 CSS USDA FINI Prog Mgnt 20157001823357 Amd 6 10.331 333.10.33 01/01/18 09/30/18 10/01/17 09/30/18 ($95,842)

FFY18 CSS USDA FINI Prog Mgnt 20157001823357 Amd 2 10.331 333.10.33 01/01/18 09/30/18 10/01/17 09/30/18 $55,060

FFY18 CSS USDA FINI Prog Mgnt 20157001823357 N/A 10.331 333.10.33 01/01/18 09/30/18 10/01/17 09/30/18 $90,782

FFY20 CSS IAR SNAP Ed Prog Mgnt-Region 5 207WAWA5Q3903 Amd 10 10.561 333.10.56 10/01/19 09/30/20 10/01/19 09/30/20 $83,000 $83,000 $83,000

FFY19 CSS IAR SNAP Ed Program Mgnt 197WAWA5Q3903 Amd 9 10.561 333.10.56 10/01/18 09/30/19 10/01/18 09/30/19 $708 $69,875 $159,906

FFY19 CSS IAR SNAP Ed Program Mgnt 197WAWA5Q3903 Amd 4 10.561 333.10.56 10/01/18 09/30/19 10/01/18 09/30/19 $69,167

FFY18 CSS IAR SNAP Ed Program Mgnt CF 187WAWA5Q3903 Amd 4 10.561 333.10.56 10/01/18 09/30/19 10/01/18 09/30/19 $13,833 $13,833

FFY18 CSS IAR SNAP Ed Program Mgnt 187WAWA5Q3903 Amd 4 10.561 333.10.56 01/01/18 09/30/18 10/01/17 09/30/18 $8,150 $69,281

FFY18 CSS IAR SNAP Ed Program Mgnt 187WAWA5Q3903 Amd 2 10.561 333.10.56 01/01/18 09/30/18 10/01/17 09/30/18 $26,548

FFY18 CSS IAR SNAP Ed Program Mgnt 187WAWA5Q3903 N/A 10.561 333.10.56 01/01/18 09/30/18 10/01/17 09/30/18 $34,583

FFY17 CSS IAR SNAP Ed Program Mgnt CF 1717WAWA5Q390 N/A 10.561 333.10.56 01/01/18 09/30/18 10/01/17 09/30/18 $6,917 $6,917

FFY19 Housing People with AIDS Formula WAH18-F999 Amd 8 14.241 333.14.24 07/01/19 06/30/20 07/01/19 06/30/20 $53,379 $53,379 $141,402

FFY18 Housing People with AIDS Formula WAH18-F999 Amd 8 14.241 333.14.24 07/01/18 06/30/19 07/01/18 06/30/19 $36,083 $88,023

FFY18 Housing People with AIDS Formula WAH18-F999 Amd 5 14.241 333.14.24 07/01/18 06/30/19 07/01/18 06/30/19 $51,940

PS SSI 1-5 BEACH Task 4 01J18001 Amd 7 66.123 333.66.12 03/01/19 10/31/19 07/01/17 10/31/19 $5,800 $5,800 $11,600

PS SSI 1-5 BEACH Task 4 01J18001 Amd 1 66.123 333.66.12 03/01/18 10/31/18 07/01/17 06/30/19 $5,800 $5,800

PS SSI 1-5 PIC Task 4 01J18001 Amd 2, 8 66.123 333.66.12 01/01/18 09/30/19 07/01/17 06/30/19 ($50,000) $28,805 $28,805

PS SSI 1-5 PIC Task 4 01J18001 N/A, Amd 8 66.123 333.66.12 01/01/18 09/30/19 07/01/17 06/30/19 $78,805

FFY19 Swimming Beach Act Grant IAR (ECY) 01J49701 Amd 7 66.472 333.66.47 03/01/19 10/31/19 12/15/18 10/31/19 $14,000 $14,000 $28,000

FFY18 Swimming Beach Act Grant IAR (ECY) 00J75501 Amd 1 66.472 333.66.47 03/01/18 10/31/18 12/15/17 12/14/18 $14,000 $14,000

FFY17 EPR PHEP BP1 LHJ Funding NU90TP921889-01 Amd 2 93.069 333.93.06 01/01/18 06/30/18 07/01/17 07/02/18 $44,006 $163,223 $163,223

FFY17 EPR PHEP BP1 LHJ Funding NU90TP921889-01 N/A 93.069 333.93.06 01/01/18 06/30/18 07/01/17 07/02/18 $119,217

Chart of Accounts

Funding Period

Statement of Work

Funding Period

DOH Use Only

Page 1 of 6


EXHIBIT B-12








Chart of Accounts

Funding Period

Statement of Work

Funding Period

DOH Use Only

FFY18 EPR PHEP BP1 Supp LHJ Funding NU90TP921889-01 Amd 5 93.069 333.93.06 07/01/18 06/30/19 07/01/18 06/30/19 $5,318 $295,345 $295,345

FFY18 EPR PHEP BP1 Supp LHJ Funding NU90TP921889-01 Amd 4 93.069 333.93.06 07/01/18 06/30/19 07/01/18 06/30/19 $290,027

FFY19 PHEP BP1 LHJ Funding NU90TP922043 Amd 10 93.069 333.93.06 07/01/19 06/30/20 07/01/19 06/30/20 $295,345 $295,345 $295,345

FFY19 Overdose Data to Action Prev NU17CE925007 Amd 11 93.136 333.93.13 09/01/19 08/31/20 09/01/19 08/31/20 $50,000 $50,000 $50,000

FFY17 317 Ops 5NH23IP000762-05-00 N/A 93.268 333.93.26 01/01/18 06/30/18 04/01/17 06/30/18 $4,837 $4,837 $4,837

FFY17 AFIX 5NH23IP000762-05-00 Amd 2, 4 93.268 333.93.26 07/01/18 06/30/19 04/01/17 06/30/19 $27,563 $27,563 $41,821

FFY17 AFIX 5NH23IP000762-05-00 N/A 93.268 333.93.26 01/01/18 06/30/18 04/01/17 06/30/18 $14,258 $14,258

FFY17 Increasing Immunization Rates NH23IP000762 Amd 3, 4 93.268 333.93.26 07/01/18 06/30/19 07/01/18 06/30/19 $16,134 $16,134 $16,134

FFY20 PPHF Ops NH23IP922619 Amd 9 93.268 333.93.26 07/01/19 06/30/20 07/01/19 06/30/20 $2,500 $2,500 $5,000

FFY17 PPHF Ops NH23IP000762 Amd 3, 4 93.268 333.93.26 07/01/18 06/30/19 04/01/18 06/30/19 $2,500 $2,500

FFY20 VFC IQIP NH23IP922619 Amd 9 93.268 333.93.26 07/01/19 06/30/20 07/01/19 06/30/20 $27,588 $27,588 $27,588

FFY20 VFC Ops NH23IP922619 Amd 9 93.268 333.93.26 07/01/19 06/30/20 07/01/19 06/30/20 $16,134 $16,134 $23,188

FFY17 VFC Ops 5NH23IP000762-05-00 N/A 93.268 333.93.26 01/01/18 06/30/18 04/01/17 06/30/18 $7,054 $7,054

FFY19 Tobacco Prevention U58DP006004 Amd 9 93.305 333.93.30 03/29/19 04/28/20 03/29/19 04/28/20 $24,482 $24,482 $35,494

FFY19 Tobacco Prevention U58DP006004 Amd 9 93.305 333.93.30 03/29/19 06/30/19 03/29/19 03/28/20 ($6,120) $0

FFY19 Tobacco Prevention U58DP006004 Amd 8 93.305 333.93.30 03/29/19 06/30/19 03/29/19 03/28/20 $6,120

FFY18 Tobacco Prevention U58DP006004 Amd 2 93.305 333.93.30 03/29/18 03/28/19 03/29/18 03/28/19 $11,012 $11,012

FFY19 Phys Actvty & Nutrition Prog NU58DP006504 Amd 10 93.439 333.93.43 09/30/19 09/29/20 09/30/19 09/29/20 $60,000 $60,000 $120,000

FFY18 Phys Actvty & Nutrition Prog NU58DP006504 Amd 8 93.439 333.93.43 03/01/19 09/29/19 09/28/18 09/29/19 $60,000 $60,000

FFY17 TCPI PTN Contracts 1L1331455 Amd 1, 3 93.638 333.93.63 01/01/18 09/28/18 09/29/17 09/28/18 $73,117 $73,117 $73,117

FFY18 PHBG Tobacco PPHF NB01OT009234 Amd 4 93.758 333.93.75 10/01/18 09/30/19 10/01/18 09/30/19 $40,000 $40,000 $69,034

FFY17 PHBG Tobacco PPHF NB01OT00918 Amd 3 93.758 333.93.75 01/01/18 09/29/18 07/01/17 09/30/18 $3,235 $29,034

FFY17 PHBG Tobacco PPHF NB01OT00918 Amd 2, 3 93.758 333.93.75 01/01/18 09/29/18 07/01/17 09/30/18 $5,799

FFY17 PHBG Tobacco PPHF NB01OT00918 N/A, Amd 3 93.758 333.93.75 01/01/18 09/29/18 07/01/17 09/30/18 $20,000

Page 2 of 6


EXHIBIT B-12








Chart of Accounts

Funding Period

Statement of Work

Funding Period

DOH Use Only

FFY17 EPR HPP BP1 Healthcare System Prep NU90TP921889-01 Amd 2 93.889 333.93.88 01/01/18 06/30/18 07/01/17 07/02/18 $4,477 $18,420 $18,420

FFY17 EPR HPP BP1 Healthcare System Prep NU90TP921889-01 N/A 93.889 333.93.88 01/01/18 06/30/18 07/01/17 07/02/18 $13,943

FFY19 RW HIV Peer Nav Proj-Proviso 5X07HA000832800 Amd 8 93.917 333.93.91 04/01/19 06/30/19 04/01/19 06/30/19 $14,353 $14,353 $71,765

FFY18 RW HIV Peer Nav Proj-Proviso 5X07HA000832800 Amd 4 93.917 333.93.91 04/01/18 03/31/19 04/01/18 03/31/19 $22,871 $57,412

FFY18 RW HIV Peer Nav Proj-Proviso 5X07HA000832800 Amd 2, 4 93.917 333.93.91 04/01/18 03/31/19 04/01/18 03/31/19 $34,541

FFY18 RW HIV Provider Capacity-Proviso 5X07HA000832800 Amd 2, 4 93.917 333.93.91 04/01/18 03/31/19 04/01/18 03/31/19 $30,695 $30,695 $30,695

FFY19 Ryan White Supp Direct Svcs 5X07HA000832800 Amd 12 93.917 333.93.91 09/30/19 06/30/20 09/30/19 09/29/20 $109,140 $109,140 $109,140

FFY20 MCHBG LHJ Contracts B04MC32578 Amd 10 93.994 333.93.99 10/01/19 09/30/20 10/01/19 09/30/20 $159,854 $159,854 $439,599

FFY19 MCHBG LHJ Contracts B04MC32578 Amd 4 93.994 333.93.99 10/01/18 09/30/19 10/01/18 09/30/19 $159,854 $159,854

FFY18 MCHBG LHJ Contracts B04MC31524 N/A 93.994 333.93.99 01/01/18 09/30/18 10/01/17 09/30/18 $119,891 $119,891

GFS-Group B (FO-SW) Amd 10 N/A 334.04.90 07/01/20 12/31/20 07/01/19 06/30/21 $10,000 $10,000 $20,000

GFS-Group B (FO-SW) Amd 10 N/A 334.04.90 07/01/19 06/30/20 07/01/19 06/30/21 $10,000 $10,000

GFS-Group B (FO-SW) Amd 3 N/A 334.04.90 01/01/18 06/30/18 07/01/17 06/30/19 ($10,000) $0

GFS-Group B (FO-SW) N/A N/A 334.04.90 01/01/18 06/30/18 07/01/17 06/30/19 $10,000

FY2 Group B Programs for DW (FO-SW) Amd 3 N/A 334.04.90 07/01/18 06/30/19 07/01/18 06/30/19 $10,000 $10,000 $30,000

FY1 Group B Programs for DW (FO-SW) Amd 3 N/A 334.04.90 01/01/18 06/30/18 01/01/18 06/30/18 $20,000 $20,000

Healthy Communities Amd 12 N/A 334.04.91 07/01/19 06/30/20 07/01/19 06/30/21 ($3,425) $0 $0

Healthy Communities Amd 10 N/A 334.04.91 07/01/19 06/30/20 07/01/19 06/30/21 $3,425

State Drug User Health Program Amd 9 N/A 334.04.91 07/01/19 06/30/20 07/01/19 06/30/21 $40,000 $40,000 $94,478

State Drug User Health Program Amd 8 N/A 334.04.91 01/01/19 06/30/19 07/01/18 06/30/19 $54,478 $54,478

State HIV CS/End AIDS WA Amd 8 N/A 334.04.91 01/01/19 06/30/19 07/01/17 06/30/19 $2,083 $12,496 $23,948

State HIV CS/End AIDS WA Amd 6 N/A 334.04.91 01/01/19 06/30/19 07/01/17 06/30/19 $10,413

State HIV CS/End AIDS WA Amd 6 N/A 334.04.91 10/01/18 12/31/18 07/01/17 06/30/19 $2,083 $2,083



Page 3 of 6


EXHIBIT B-12








Chart of Accounts

Funding Period

Statement of Work

Funding Period

DOH Use Only

State HIV Prevention Amd 8 N/A 334.04.91 01/01/19 06/30/19 07/01/17 06/30/19 ($43,333) $0 $51,667

State HIV Prevention Amd 6 N/A 334.04.91 01/01/19 06/30/19 07/01/17 06/30/19 $43,333

State HIV Prevention Amd 6 N/A 334.04.91 07/01/18 12/31/18 07/01/17 06/30/19 $11,667 $31,667

State HIV Prevention N/A N/A 334.04.91 07/01/18 12/31/18 07/01/17 06/30/19 $20,000

State HIV Prevention N/A N/A 334.04.91 01/01/18 06/30/18 07/01/17 06/30/19 $20,000 $20,000

State HIV Prevention PrEP Amd 3 N/A 334.04.91 07/01/18 06/30/19 07/01/17 06/30/17 $9,172 $9,172 $13,758

State HIV Prevention PrEP Amd 2 N/A 334.04.91 01/01/18 06/30/18 07/01/17 06/30/19 $4,586 $4,586

FPH Lead Case Mgmt-FPH Amd 12 N/A 334.04.93 07/01/19 06/30/20 07/01/19 06/30/20 $3,425 $3,425 $3,425

SFY2 Lead Environments of Children Amd 7 N/A 334.04.93 07/01/18 06/30/19 07/01/18 06/30/19 ($3,000) $2,000 $5,000

SFY2 Lead Environments of Children Amd 4 N/A 334.04.93 07/01/18 06/30/19 07/01/18 06/30/19 $5,000

SFY1 Lead Environments of Children Amd 1 N/A 334.04.93 01/01/18 06/30/18 07/01/17 06/30/18 $3,000 $3,000

SFY20 Marijuana Education Amd 10 N/A 334.04.93 07/01/19 06/30/20 07/01/19 06/30/20 $5,950 $5,950 $5,950

SFY21 Marijuana Tobacco Edu Amd 9 N/A 334.04.93 07/01/20 12/31/20 07/01/20 06/30/21 $247,509 $247,509 $898,341

SFY20 Marijuana Tobacco Edu Amd 9 N/A 334.04.93 07/01/19 06/30/20 07/01/19 06/30/20 $247,509 $247,509




SFY18 Marijuana Tobacco Edu N/A N/A 334.04.93 01/01/18 06/30/18 07/01/17 06/30/18 $98,755

Rec Shellfish/Biotoxin Amd 9 N/A 334.04.93 07/01/19 06/30/20 07/01/19 06/30/21 $15,000 $15,000 $37,500

Rec Shellfish/Biotoxin N/A N/A 334.04.93 01/01/18 06/30/19 07/01/17 06/30/19 $22,500 $22,500

Small Onsite Management (ALEA) Amd 9 N/A 334.04.93 07/01/19 06/30/20 07/01/19 06/30/21 $45,000 $45,000 $75,000

Small Onsite Management (ALEA) Amd 5 N/A 334.04.93 07/01/18 06/30/18 07/01/17 06/30/19 $15,662 $15,662

Small Onsite Management (ALEA) Amd 5 N/A 334.04.93 01/01/18 06/30/18 07/01/17 06/30/19 ($15,662) $14,338

Small Onsite Management (ALEA) N/A, Amd 5 N/A 334.04.93 01/01/18 06/30/18 07/01/17 06/30/19 $30,000

.

Wastewater Management-GFS Amd 9 N/A 334.04.93 07/01/20 12/31/20 07/01/19 06/30/21 $15,000 $15,000 $45,000

Wastewater Management-GFS N/A N/A 334.04.93 07/01/18 06/30/19 07/01/17 06/30/19 $30,000 $30,000

Page 4 of 6


EXHIBIT B-12








Chart of Accounts

Funding Period

Statement of Work

Funding Period

DOH Use Only

FPH-Youth Tobacco Vapor Prevention Amd 11 N/A 334.04.93 07/01/19 06/30/20 07/01/19 06/30/21 $24,512 $24,512 $24,512

Youth Tobacco Vapor Products Amd 11 N/A 334.04.93 07/01/19 06/30/20 07/01/19 06/30/21 ($8,451) $38,403 $121,091

Youth Tobacco Vapor Products Amd 9 N/A 334.04.93 07/01/19 06/30/20 07/01/19 06/30/21 $46,854

Youth Tobacco Vapor Products Amd 6 N/A 334.04.93 01/01/18 06/30/19 07/01/17 06/30/19 $36,000 $82,688

Youth Tobacco Vapor Products Amd 2, 6 N/A 334.04.93 01/01/18 06/30/19 07/01/17 06/30/19 $25,544

Youth Tobacco Vapor Products Amd 2, 6 N/A 334.04.93 01/01/18 06/30/19 07/01/17 06/30/19 $4,655

Youth Tobacco Vapor Products N/A, Amd 6 N/A 334.04.93 01/01/18 06/30/19 07/01/17 06/30/19 $16,489

ADAP Rebate (Local) 19-21 Amd 9 N/A 334.04.98 07/01/19 06/30/20 07/01/19 06/30/21 $91,728 $91,728 $91,728

FFY17 ADAP Rebate (Local) 17-19 Amd 5 N/A 334.04.98 07/01/18 06/30/19 07/01/17 06/30/19 ($225,000) $82,556 $348,834

FFY17 ADAP Rebate (Local) 17-19 Amd 3 N/A 334.04.98 07/01/18 06/30/19 07/01/17 06/30/19 $82,556

FFY17 ADAP Rebate (Local) 17-19 N/A, Amd 3 N/A 334.04.98 07/01/18 06/30/19 07/01/17 06/30/19 $225,000

FFY17 ADAP Rebate (Local) 17-19 Amd 2 N/A 334.04.98 01/01/18 06/30/18 07/01/17 06/30/19 $41,278 $266,278

FFY17 ADAP Rebate (Local) 17-19 N/A N/A 334.04.98 01/01/18 06/30/18 07/01/17 06/30/19 $225,000

SFY17 Managed Care Org Amd 1 N/A 334.04.98 01/01/18 06/30/18 07/01/17 06/30/18 ($32,678) $6,536 $6,536

SFY17 Managed Care Org N/A N/A 334.04.98 01/01/18 06/30/18 07/01/17 06/30/18 $39,214

FFY20 RW Grant Year Local (Rebate) Amd 12 N/A 334.04.98 04/01/20 06/30/20 04/01/20 03/31/21 ($27,285) $88,861 $804,903

FFY20 RW Grant Year Local (Rebate) Amd 9 N/A 334.04.98 04/01/20 06/30/20 04/01/20 03/31/21 $116,146

FFY19 RW Grant Year Local (Rebate) Amd 12 N/A 334.04.98 07/01/19 03/31/20 04/01/19 03/31/20 ($81,855) $266,582

FFY19 RW Grant Year Local (Rebate) Amd 9 N/A 334.04.98 07/01/19 03/31/20 04/01/19 03/31/20 $348,437

FFY19 RW Grant Year Local (Rebate) Amd 6 N/A 334.04.98 04/01/19 06/30/19 04/01/19 03/31/20 $112,230 $112,230



FFY19 RW Local Proviso Amd 9 N/A 334.04.98 07/01/19 06/30/20 07/01/19 06/30/20 $41,749 $41,749 $41,749

FPHS Funding for LHJs Amd 10 N/A 336.04.25 07/01/20 12/31/20 07/01/19 06/30/21 $147,345 $147,345 $442,035

FPHS Funding for LHJs Amd 10 N/A 336.04.25 07/01/19 06/30/20 07/01/19 06/30/21 $147,345 $147,345

FPHS Funding for LHJs Dir Amd 3 N/A 336.04.25 07/01/18 06/30/19 07/01/17 06/30/19 $147,345 $147,345

Page 5 of 6


EXHIBIT B-12








Chart of Accounts

Funding Period

Statement of Work

Funding Period

DOH Use Only

YR 20 SRF - Local Asst (15%) (FS) SS Amd 3 N/A 346.26.64 01/01/18 12/31/18 07/01/15 12/31/18 ($14,750) $0 $0

YR 20 SRF - Local Asst (15%) (FS) SS N/A, Amd 3 N/A 346.26.64 01/01/18 12/31/18 07/01/15 12/31/18 $14,750

YR 21 SRF - Local Asst (15%) (FS) SS Amd 10 N/A 346.26.64 01/01/18 06/30/19 07/01/17 06/30/19 ($13,250) $14,250 $14,250

YR 21 SRF - Local Asst (15%) (FS) SS Amd 6, 10 N/A 346.26.64 01/01/18 06/30/19 07/01/17 06/30/19 $12,750

YR 21 SRF - Local Asst (15%) (FS) SS Amd 3, 6, 10 N/A 346.26.64 01/01/18 06/30/19 07/01/17 06/30/19 $14,750

YR 22 SRF - Local Asst (15%) (FO-SW) SS Amd 12 N/A 346.26.64 01/01/19 12/31/20 07/01/19 06/30/21 $8,500 $21,250 $21,250

YR 22 SRF - Local Asst (15%) (FO-SW) SS Amd 10, 12 N/A 346.26.64 01/01/19 12/31/20 07/01/19 06/30/21 $12,750

YR 20 SRF - Local Asst (15%) (FS) TA Amd 3 N/A 346.26.66 01/01/18 12/31/18 07/01/15 12/31/18 ($2,000) $0 $0

YR 20 SRF - Local Asst (15%) (FS) TA N/A, Amd 3 N/A 346.26.66 01/01/18 12/31/18 07/01/17 12/31/18 $2,000

YR 20 SRF - Prog Mgmt (10%) (FS) TA Amd 6 N/A 346.26.66 01/01/18 12/31/18 07/01/15 12/31/18 $468 $1,268 $1,268

YR 20 SRF - Prog Mgmt (10%) (FS) TA Amd 3 N/A 346.26.66 01/01/18 12/31/18 07/01/15 12/31/18 $800

YR 21 SRF - Local Asst (15%) (FS) TA Amd 10 N/A 346.26.66 01/01/18 06/30/19 07/01/17 06/30/19 ($1,249) $1,900 $1,900

YR 21 SRF - Local Asst (15%) (FS) TA Amd 6, 10 N/A 346.26.66 01/01/18 06/30/19 07/01/17 06/30/19 $1,949

YR 21 SRF - Local Asst (15%) (FS) TA Amd 3, 6, 10 N/A 346.26.66 01/01/18 06/30/19 07/01/17 06/30/19 $1,200

YR 22 SRF - Local Asst (15%) (FO-SW) TA Amd 12 N/A 346.26.66 01/01/19 12/31/20 07/01/19 06/30/21 $3,000 $4,249 $4,249

YR 22 SRF - Local Asst (15%) (FO-SW) TA Amd 10, 12 N/A 346.26.66 01/01/19 12/31/20 07/01/19 06/30/21 $1,249

TOTAL $5,716,677 $5,716,677

Total consideration: $5,705,177 GRAND TOTAL $5,716,677

$11,500

GRAND TOTAL $5,716,677 Total Fed $2,488,305

Total State $3,228,372

*Catalog of Federal Domestic Assistance

**Federal revenue codes begin with "333". State revenue codes begin with "334".

Page 6 of 6


Exhibit C-12 Schedule of Federal Awards AMENDMENT #12

Date: November 15, 2019

DOH Total Amt

Chart of Accounts Program Title BARSFederal

Award Date

Federal

Award

Start

Date

End

DateContract Amt CFDA CFDA Program Title Federal Agency Name

Federal Award

Identification NumberFederal Grant Award Name

FFY20 CSS USDA FINI PROGRAM MGMT 333.10.33 04/01/15 $5,859,307 10/01/19 03/31/20 $25,000 10.331Food Insecurity Nutrition Incentive

Grants

USDA-National Institute of Food and

Agriculture20157001823357 FOOD NUTRITION INCENTIVE GRANT


Grants


Agriculture20157001823357

WASHINGTON STATE DEPARTMENT

OF HEALTH FINI GRANT PROJECT


Grants


Agriculture20157001823357


OF HEALTH FINI GRANT PROJECT

FFY20 CSS IAR SNAP ED PROG MGNT-REGION 5 333.10.56 09/30/19 $5,300,000 10/01/19 09/30/20 $83,000 10.561

State Administrative Matching

Grants for the Supplemental

Nutrition Assistance Program

Department of Agriculture Food and

Nutrition Service207WAWA5Q3903

2019 SUPPLEMENTAL NUTRITION

ASSISTANCE PROGRAM EDUCATION

(SNAP-ED)

FFY19 CSS IAR SNAP-ED PROG MGNT 333.10.56 09/28/18 $5,386,268 10/01/18 09/30/19 $69,875 10.561





Nutrition Service197WAWA5Q3903 SNAP 2YR NUTRITION ED OBESITY

FFY18 CSS IAR SNAP-ED PROGRAM MGNT CF 333.10.56 09/28/17 $5,300,000 10/01/18 09/30/19 $13,833 10.561








(SNAP-ED)

FFY18 CSS IAR SNAP-ED PROGRAM MGNT 333.10.56 09/28/17 $5,300,000 01/01/18 09/30/18 $69,281 10.561








(SNAP-ED)

FFY17 CSS IAR SNAP-ED PROGRAM MGNT CF 333.10.56 09/10/16 $5,739,856 01/01/18 09/30/18 $6,917 10.561








(SNAP-ED)

FFY19 HOUSING PEOPLE WITH AIDS FORMULA 333.14.24 08/07/18 $955,996 07/01/19 06/30/20 $53,379 14.241Housing Opportunities for

Persons with AIDS

Department of Housing and Urban

DevelopmentWAH18-F999

HOUSING OPPORTUNITIES FOR

PERSON WITH AIDS (HOPWA)

PROGRAM

FFY18 HOUSING PEOPLE WITH AIDS FORMULA 333.14.24 08/07/18 $955,996 07/01/18 06/30/19 $88,023 14.241Housing Opportunities for

Persons with AIDS

Department of Housing and Urban

DevelopmentWAH18-F999

HOUSING OPPORTUNITIES FOR

PERSON WITH AIDS (HOPWA)

PROGRAM

PS SSI 1-5 PIC TASK 4 333.66.12 08/02/16 $9,200,000 01/01/18 09/30/19 $28,805 66.123

Puget Sound Action Agenda:

Technical Investigations and

Implementation Assistance

Program

Environmental Protection Agency

Region 1001J18001

PUGET SOUND SHELLFISH

STRATEGIC INITIATIVE LEAD

PS SSI 1-5 BEACH TASK 4 333.66.12 08/02/16 $9,200,000 03/01/18 10/31/19 $11,600 66.123

Puget Sound Action Agenda:

Technical Investigations and

Implementation Assistance

Program


Region 1001J18001

PUGET SOUND SHELLFISH

STRATEGIC INITIATIVE LEAD

FFY19 SWIMMING BEACH ACT GRANT IAR (ECY) 333.66.47 12/01/18 $91,991 03/01/19 10/31/19 $14,000 66.472Beach Monitoring and Notificaiton

Program Implementation Grants


Office of Water01J49701

MARINE SWIMMING BEACH

MONITORING AND PUBLIC

NOTIFICATION

FFY18 SWIMMING BEACH ACT GRANT IAR (ECY) 333.66.47 12/15/17 $91,990 03/01/18 10/31/18 $14,000 66.472Beach Monitoring and Notificaiton

Program Implementation Grants


Office of Water00J75501

MARINE SWIMMING BEACH

MONITORING AND PUBLIC

NOTIFICATION

FFY19 PHEP BP1 LHJ FUNDING 333.93.06 06/29/19 $11,307,904 07/01/19 06/30/20 $295,345 93.069Public Health Emergency

Preparedness

Department of Health and Human

Services Centers for Disease Control

and Prevention

NU90TP922043

PUBLIC HEALTH EMERGENCY

PREPAREDNESS (PHEP)

COOPERATIVE AGREEMENT

FFY18 EPR PHEP BP1 SUPP LHJ FUNDING 333.93.06 08/01/18 $11,062,782 07/01/18 06/30/19 $295,345 93.069Public Health Emergency

Preparedness



and Prevention

NU90TP921889-01

HOSPITAL PREPAREDNESS

PROGRAM AND PUBLIC HEALTH

EMERGENCY PREPAREDNESS


Allocation Period

KITSAP PUBLIC HEALTH DISTRICT-SWV0027359-00

CONTRACT CLH18248-Kitsap Public Health District

CONTRACT PERIOD: 01/01/2018-12/31/2020

Page 1 of 3



DOH Total Amt


Award Date

Federal

Award

Start

Date

End


Federal Award


Allocation Period



CONTRACT PERIOD: 01/01/2018-12/31/2020

FFY17 EPR PHEP BP1 LHJ FUNDING 333.93.06 07/18/17 $11,062,782 01/01/18 06/30/18 $163,223 93.069Public Health Emergency

Preparedness



and Prevention

NU90TP921889-01

HOSPITAL PREPAREDNESS

PROGRAM AND PUBLIC HEALTH

EMERGENCY PREPAREDNESS


FFY19 OVERDOSE DATA TO ACTION PREV 333.93.13 08/12/19 $4,390,240 09/01/19 08/31/20 $50,000 93.136

Injury Prevention and Control

Research and State and

Community-Based Programs


Services-Centers for Disease Control

and Prevention-National Center for

Injury Prevention and Control

NU17CE925007


OF HEATLH OVERDOSE DATA TO

ACTION

FFY20 VFC OPS 333.93.26 07/01/19 $9,234,835 07/01/19 06/30/20 $16,134 93.268Immunization Cooperative

Agreements



and Prevention

NH23IP922619IMMUNIZATION GRANT AND

VACCINES FOR CHILDREN PROGRAM

FFY20 VFC IQIP 333.93.26 07/01/19 $9,234,835 07/01/19 06/30/20 $27,588 93.268Immunization Cooperative

Agreements



and Prevention



FFY20 PPHF OPS 333.93.26 07/01/19 $9,234,835 07/01/19 06/30/20 $2,500 93.268Immunization Cooperative

Agreements



and Prevention



FFY17 VFC OPS 333.93.26 03/03/17 $1,201,605 01/01/18 06/30/18 $7,054 93.268Immunization Cooperative

Agreements



and Prevention

5NH23IP000762-05-00

IMMUNIZATION GRANT AND

VACCINES FOR CHILDREN'S

PROGRAM

FFY17 PPHF OPS 333.93.26 06/29/18 $3,634,512 07/01/18 06/30/19 $2,500 93.268Immunization Cooperative

Agreements



and Prevention

NH23IP000762



PROGRAM

FFY17 INCREASING IMMUNIZATION RATES 333.93.26 06/29/18 $1,722,443 07/01/18 06/30/19 $16,134 93.268Immunization Cooperative

Agreements



and Prevention

NH23IP000762



PROGRAM

FFY17 AFIX 333.93.26 03/03/17 $1,672,289 01/01/18 06/30/19 $41,821 93.268Immunization Cooperative

Agreements



and Prevention

5NH23IP000762-05-00



PROGRAM

FFY17 317 OPS 333.93.26 03/03/17 $575,969 01/01/18 06/30/18 $4,837 93.268Immunization Cooperative

Agreements



and Prevention

5NH23IP000762-05-00



PROGRAM

FFY19 TOBACCO PREVENTION 333.93.30 03/04/19 $5,538,507 03/29/19 04/28/20 $24,482 93.305National State Based Tobacco

Control Programs



and Prevention

NU58DP006004 TOBACCO CONTROL PROGRAM

FFY18 TOBACCO PREVENTION 333.93.30 03/22/18 $1,081,051 03/29/18 03/29/19 $11,012 93.305National State Based Tobacco

Control Programs



and Prevention

U58DP006004 TOBACCO CONTROL PROGRAM

FFY19 PHYS ACTVTY & NUTRITION PROG 333.93.43 07/24/19 $1,846,000 09/30/19 09/29/20 $60,000 93.439State Physical Activity and

Nutrition (SPAN)


Services (HHS) Centers for Disease

Control and Prevention (CDC)

NU58DP006504STATE PHYSICAL ACTIVITY AND

NUTRITION-WASHINGTON (SPANWA)

FFY18 PHYS ACTVTY & NUTRITION PROG 333.93.43 09/01/18 $923,000 03/01/19 09/29/19 $60,000 93.439State Physical Activity and

Nutrition (SPAN)


ServicesNU58DP006504

STATE PHYSICAL ACTIVITY AND

NUTRITION-WASHINGTON (SPANWA)

FFY17 TCPI PTN CONTRACTS 333.93.63 09/24/15 $11,254,883 01/01/18 09/28/18 $73,117 93.638

ACA-Transforming Clinical

Practice Initiative: Practice

Transformation Networks (PTNs)


Services Centers for Medicare and

Medicaid Services

1L1331455TRANSFORMING CLINICAL

PRACTICES INITIATIVE

FFY18 PHBG TOBACCO PPHF 333.93.75 08/31/18 $1,675,032 10/01/18 09/30/19 $40,000 93.758

Preventive Health and Health

Services Block Grant funded

solely with Prevention and Public

Health Funds (PPHF)


Services Health Centers for Disease

Control and Prevention

NB01OT009234PREVENTIVE HEALTH AND HEALTH

SERVICES BLOCK GRANT 2018

Page 2 of 3




DOH Total Amt


Award Date

Federal

Award

Start

Date

End


Federal Award


Allocation Period



CONTRACT PERIOD: 01/01/2018-12/31/2020

FFY17 PHBG TOBACCO PPHF 333.93.75 03/09/17 $1,557,831 01/01/18 09/29/18 $29,034 93.758

Preventive Health and Health

Services Block Grant funded

solely with Prevention and Public

Health Funds (PPHF)


Services Health Centers for Disease

Control and Prevention

NB01OT00918PREVENTIVE HEALTH AND HEALTH

SERVICES BLOCK GRANT

FFY17 EPR HPP BP1 HEALTHCARE SYS PREP 333.93.88 07/18/17 $4,279,234 01/01/18 06/30/18 $18,420 93.889Public Health Emergency

Preparedness



and Prevention

NU90TP921889-01HPP AND PHEP COOPERATIVE

AGREEMENT

FFY19 RYAN WHITE SUPP DIRECT SVCS 333.93.91 04/02/18 $13,631,623 09/30/19 06/30/20 $109,140 93.917 HIV Care Formula Grants


Services Health Resources and

Services Administration

5X07HA000832800 RYAN WHITE CARE ACT TITLE II

FFY19 RW HIV PEER NAV PROJ-PROVISO 333.93.91 04/02/18 $13,631,623 04/01/19 06/30/19 $14,353 93.917 HIV Care Formula Grants





FFY18 RW HIV PROVIDER CAPACITY-PROVISO 333.93.91 04/02/18 $13,631,623 04/01/18 03/31/19 $30,695 93.917 HIV Care Formula Grants





FFY18 RW HIV PEER NAV PROJ-PROVISO 333.93.91 04/02/18 $13,631,623 04/01/18 03/31/19 $57,412 93.917 HIV Care Formula Grants





FFY20 MCHBG LHJ CONTRACTS 333.93.99 11/14/18 $2,225,977 10/01/19 09/30/20 $159,854 93.994

Maternal and Child Health

Services Block Grant to the

States




B04MC32578MATERNAL AND CHILD HEALTH





States









States





SERVICES

TOTAL $2,488,305

Page 3 of 3


Wednesday, January 29, 2020Kitsap Public Health District

KPHDProgram

ContractType

ContractLength

KPHB Approved

ContractAmount

StartDate

EndDate

KPHDContract ID

SignedDate

New or Renewed Contracts for the Period of 12/01/2019 through 12/31/2019

Client Contract ID

Active (2 contracts)

Olympic Educational Service DistrictCommunity Health, Yolanda Fong Contract for Services Closed 11/04/19 $54,750.00 11/01/19 10/31/20ID: 2030 12/02/19

Description: The District to provide services, training, and technical assistance appropriate to the needs of Head Start, ECEAP, and Early Head Start staff and enrollees, including public health nurse support to the Early Head Start home-based services to 44 eligible families.

Community Health, Yolanda Fong Contract for Services Closed $1,500.00 11/01/19 10/31/20ID: 2031 12/02/19

Description: KPHD to provide TB testing and certification for designated OESD 114 Early Learning Department staff, substitutes and volunteers.

07:58 AM Page 1 of 1

09200 Account Ledger Inquiry From Date/Period 12/01/19 Account. . . . . . 95969.2315 Thru Date/Period 12/11/19 ACCRUED EMPLOYEE BENEFITS Ledger Type. . . AA Skip to Doc/Type . Subledger. . . . * Y-T-D Period End . 3,085.92- Cumul Period End . 112,332.81- Additional Selections Exist O DT Document Date Explanation/Alpha Debit Credit P U1 368606 12/11/19 DAILY CASH TRANSMI 20,400.17 P U1 368606 12/11/19 DAILY CASH TRANSMI 94,057.16 P ----------------- ----------------- 114,457.33 Ledger Total 114,457.33 Unposted Total Opt: 1/2=Orig Entry 5=Details F17=Top F18=Totals F21=Prt Ledg F24=More

09200 Account Ledger Inquiry From Date/Period 12/01/19 Account. . . . . . 95969.2317 Thru Date/Period 12/31/19 ACCRUED TAXES Ledger Type. . . AA Skip to Doc/Type . Subledger. . . . * Y-T-D Period End . Cumul Period End . Additional Selections Exist O DT Document Date Explanation/Alpha Debit Credit P U1 369261 12/31/19 DAILY CASH TRANSMI 139,919.60 P ----------------- ----------------- 139,919.60 Ledger Total 139,919.60 Unposted Total Opt: 1/2=Orig Entry 5=Details F17=Top F18=Totals F21=Prt Ledg F24=More

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